Prevalence of Irritable Bowel Syndrome (IBS) in the Arab World: A Systematic Review

Irritable Bowel Syndrome (IBS) is a common functional pathology of the gastrointestinal tract (GIT) across the globe. The prevalence rate of IBS varies across the regions. In the present systematic review, we aim to investigate the prevalence of IBS in Arab countries in recent years. To identify relevant studies, a comprehensive search was undertaken in various databases including CINAHL (Cumulated Index to Nursing and Allied Health Literature) Ultimate, Scopus, PubMed, and Web of Science. Furthermore, Google Scholar was also explored to identify relevant studies. The inclusion criteria included studies that assessed IBS in the Arab world and were published in the English language. Fifty-two cross-sectional studies from seven countries, encompassing 51,683 participants, were included. The majority of the included studies were conducted in Saudi Arabia (n=40), followed by Jordan (n=4) and Egypt (n=3). The highest prevalence rates were reported by studies from Saudi Arabia, Lebanon, and Jordan. Low prevalence rates (<20%) were noted in 19 studies included in this systematic review. Female predominance in IBS prevalence was observed in most studies, while only two studies indicated higher prevalence in males. Key risk factors included family history, anxiety, depression, gastroesophageal reflux disease, low income, diabetes, low water intake, workload, occupation, food allergy, smoking, age, chronic diseases, and stress. IBS prevalence in the Arab world varies significantly. Female predominance was seen in the present systematic review as well.


Introduction And Background
Irritable bowel syndrome (IBS) is a chronic functional pathology of the gastrointestinal tract (GIT).This disease is characterized by chronic abdominal pain, bloating, and altered bowel habits, which can significantly impair the quality of life [1].The severity of symptoms varies in different individuals with some experiencing severe disease whereas others experiencing mild symptoms.The pathophysiology of IBS is not completely understood; however, it is believed to be a multifactorial pathology [2,3].Due to variations in symptoms, the diagnosis of IBS poses challenges.Furthermore, there is a lack of precise biomarkers and sensitivity and specificity testing.Different diagnostic guidelines have been proposed such as Kruis scoring system and Manning and Rome criteria.The Rome I, II, and III criteria have been widely adopted for the diagnosis of IBS.Recently, Rome IV criteria is the most commonly accepted criteria for IBS [4] .
IBS is a multifactorial condition with several risk factors.Previously, studies have recognized both mental and physical factors to influence the development of IBS.For example, stress has been implicated in the progression of the disease [5].Other well-known risk factors of IBS include chronic inflammation of the intestine, and altered intestinal flora [6,7].Due to the involvement of various risk factors, the prevalence of IBS is influenced by genetic, environmental, cultural, and dietary factors.Throughout the world, the prevalence of IBS varies considerably.Approximately 10-20% of the population in the world suffers from IBS. Women and individuals aged below the age of 50 years are particularly vulnerable to IBS [8].Epidemiological studies on IBS in the Arab world are relatively scarce compared to Western countries.However, the available literature suggests that the prevalence of IBS in the Arab world is comparable to, if not higher than, that in Western countries.A systematic review by Almasary et al. reported a pooled prevalence of 20.7% in Saudi Arabia [9].Their systematic review and meta-analysis included 38 studies and 26,567 participants.
The difference in prevalence in the Arab nations can be due to various factors including lifestyle, diet, and healthcare access.Traditional healthcare practices and varying levels of awareness and education about IBS among healthcare providers and the general population further complicate the epidemiological landscape of IBS in the Arab world.For example, a study by Issa et al. reported that only 50% of the participants were aware of IBS in Saudi Arabia [10].Healthcare infrastructure and access to medical care vary widely across the Arab world, affecting the diagnosis and management of IBS.In some countries, advanced healthcare facilities and specialized gastrointestinal clinics are available, while others may have limited resources.There has been a continuous rise in the prevalence of IBS in the Arab World.For example, Isbister and Hubler reported in 1998 that the prevalence of IBS is rare in Saudi Arabia [11].Similarly, a prevalence of 1.35/100 000 person-years was reported from Oman in 1997 [12].However, a systematic review by Alosaimi et al. reported a prevalence of 8.9-31.8% in the Arab world in 2016 [13].
As IBS can have a significant impact on the quality of life and healthcare systems, it is important to understand the exact prevalence of IBS in the Arab world as currently, there is a paucity of up-to-date research on this.This systematic review aimed to summarize the latest evidence on IBS in the Arab World.

Search strategy
A systemic search was carried out in various databases to identify the prevalence of IBS in the Arab World.The searched databases included PubMed, Web of Science, CINAHL (Cumulated Index to Nursing and Allied Health Literature) Ultimate, and Scopus.To further increase the relevant literature, Google Scholar was also searched.A combination of keywords was used during the search strategy.Commonly used keywords included Epidemiology," or "Incidence," "Irritable bowel syndrome," or "IBS," and "Arab World," or "Middle East".Apart from these keywords, different alternatives of the keywords were also used.The details of all the keywords are presented in the Appendix A. The inclusion criteria of this systemic review were as follows: (i) studies that investigated the prevalence of IBS in the Arab world; (ii) studies that were published in English, and (iii) studies that were published between 2019 and 2024.The exclusion criteria for the systematic review included studies that identified the prevalence of IBS but were conducted outside the Arab world.

Data collection process
Database search results were transferred to a reference manager (EndNote 20, Clarivate Plc, Philadelphia, Pennsylvania, United States).At this stage, the duplicates were removed.For screening the potential studies, the EndNote file was transferred to Rayyan, a research collaboration platform [14].Two independent reviewers were involved in the further process.In the Ryyan software, the blind was turned on to ensure that there was no bias in the selection process.Next, the selection of studies was based on the title and abstract of the studies.Finalized studies were cross-checked by both reviewers and uncommon studies were either excluded or included by discussion among reviewers.In case of any differences in opinion, a third reviewer was involved in the process to finalize the status of inclusion.After that, the detailed data from the searched studies were transferred to Excel (Microsoft Corporation, Redmond, Washington, United States), and notes about the intervention used, participants, and results were obtained.

Results
Figure 1 shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the systematic review.

Included Studies
The literature search yielded 506 studies from PubMed (n=182), CINAHL Ultimate (n=33), Scopus (n=134), Web of Science (n=128), and Google Scholar (n=29) (See Appendix B).A total of 105 duplicates were removed prior to the screening process.Out of 401 studies included in the screening process, 298 were removed based on the title and abstract.Finally, after thoroughly screening the studies, only 52 studies met the inclusion criteria for the systematic review.

Study Characteristics
The reviewed characteristics were study design, author year, country of research, number of participants along with their gender, selected population, duration of the study, diagnostic criteria used in the study, and the reported prevalence (Table 1).This systematic review included 52 cross-sectional studies from different countries of the Arab world (Saudi Arabia, Jordan, Egypt, Lebanon, Bahrain, Oman, and Tunisia) cumulating a total of 51,683 participants.All the included studies were cross-sectional studies.The sample sizes within these studies vary from the smallest at 40 [15] to the largest being 14268 [16] participants.Male and female representation across these studies display substantial variations from a full male cohort in the study of Alshahrani et al. [17] to the absence of male participants in Alharbi et al. [18] and Alanzi et al. [19].

Discussion
IBS is a chronic functional bowel disease that is described by altered stool frequency or form associated with abdominal pain and discomfort.Estimation of the worldwide prevalence of IBS is imperative for understanding the burden and distribution of the disease.The incidence and prevalence of IBS have been studied systematically but there are significant variations in the results that may be due to the designs of the study or due to geographical regions.Variations can also occur due to different methods, sampling approaches, questionnaire types, variations due to local factors, and the use of dissimilar diagnostic criteria [65].
This systematic review was aimed at reviewing the prevalence of IBS in the Arab nations.This systematic review was based on 52 studies published from 2019 to 2024 in different Arab countries.The studies included diverse populations ranging from students, medical students, school teachers, adults, and the general population of different countries.All the included studies were cross-sectional and followed Rome III and Rome IV diagnostic criteria.The range of sample size was also vast, ranging from 40 to 14268.The IBS prevalence among the included studies was variable, ranging from 7.6% to 54.8%.The average IBS prevalence across these studies was approximately 27%.
The findings of our study were in line with a recent systematic review conducted for the assessment of the prevalence of IBS in the Kingdom of Saudi Arabia including 20 studies with a total of 1708 participants.This study found that the prevalence rates for IBS in the included studies ranged from 7.9% to 49.3% and the average incidence across these studies was about 24%.The factors highlighted by this study to be significantly related to the high prevalence of IBS were female gender, anxiety, depression, emotional stress, and family history [66].A similar systematic review and meta-analysis based on 38 studies and 26,567 cumulative participants reported a pooled prevalence of IBS (20.7%) in the Saudi population [9].
Compared to our systematic review, a much lower prevalence has been reported by Oka et al. [65].Their systematic review assessed the global prevalence of IBS and included 57 studies.The observed prevalence of IBS in studies that used Rome III diagnostic criteria was 9.2% compared with 3.8% who used Rome IV diagnostic criteria.The most commonly reported type of IBS in this systematic review was the mixed type.Moreover, the prevalence of IBS was higher in women as reported in most of the studies in our review.The prevalence was variable in different countries.This variability in prevalence persisted even when similar diagnostic criteria were used with identical procedures.However, this systematic review indicated a substantially low incidence with Rome IV criteria indicating that more restrictive standards can be less appropriate for population-based prevalence surveys [65].A population-based study conducted in Iran found a very low 1.1% prevalence of IBS.The factors that were associated significantly were older age and marital status like some of the reported studies in the current review [67].However, this study was published in 2009.This also indicates an increase in IBS prevalence in the region.
As reported in the present systematic review, the higher prevalence of IBS in women has been reported previously as well.A systematic review and meta-analysis by Lovell et al. reported an odds ratio of 1.67 in women compared to men regarding IBS [68].Male predominance was also observed in two of the included studies in this systematic review [31,47].Most of the global prevalence-reported studies marked a female predominance for IBS.It is believed sex hormones may promote gender differences by affecting stress hormones, immune response, gut-brain interactions, intestinal barrier functionality, and gut microbiome [69].In their systematic review, Saito et al. found that the incidence of IBS in North America ranges from 3% to 20% [70].The prevalence estimates ranged from 10% to 15% in most of the included studies.In their meta-analysis, Lovell et al. used Rome I and II criteria and found that the prevalence values were 8.8% and 9.4% respectively.Like other studies, this prevalence was higher in females than males.Also, the reported prevalence was lower in older adults and high in younger adults [71].
The most common risk factors found, in most of the studies included in the current systematic review, to be significantly associated with high prevalence rates of IBS were similar to the findings of the previous studies specifically designed to find the risk factors for IBS [72,73].Depression and anxiety were considered to be the main culprits behind the progression of IBS.This is also evident from our study as several of the included studies found a significant association of depression and anxiety with IBS.On the other hand, IBS can also result in depression and anxiety in individuals.This was evidenced by Zamani et al. in their systematic review [74].They found that the prevalence rates of anxiety disorders and symptoms in individuals suffering from IBS were 39.1% and 23%, respectively.Depressive disorders and symptoms were calculated to be 28.8% and 23.3%, respectively.These prevalence rates were an indication that patients with IBS have 3 increased odds of depression and anxiety compared to healthy subjects.
The majority of studies included in this systematic review included students of universities.This can be due to the limitation of the methodology as the majority of the studies used a cross-sectional study design.Furthermore, the high prevalence of IBS in students as reported in most studies can be due to stress-related factors.A systematic review that assessed the prevalence of IBS in medical students reported that IBS incidence ranges from 9.3% to 35.5% [75].The prime factor for this high prevalence was a stressful environment in addition to the female gender, emotional disorders, anxiety, dietary habits, poor sleep, depression, and poor quality of sleep.Another systematic review was conducted for the assessment of the prevalence of IBS in Chinese university students [76].This systematic review reported a pooled prevalence of IBS to be 11.89%.However, this prevalence was variable among the different diagnostic criteria used in the study.The highest prevalence of IBS was 17.66% in North China and the lowest was 3.18% in South China.Similar to the current review, this study also indicated that anxiety, depression, gender, and smoking behaviors were significantly associated with the prevalence of IBS.This study did not find any definite link between caffeine to IBS, but there was a marginal rise in the risk linked with its use [77].

Conclusions
The prevalence of IBS shows significant variability across different populations and countries.The female predominance in IBS prevalence was a consistent observation across a majority of the studies reviewed.Several risk factors identified included gastroesophageal reflux disease, low income, diabetes mellitus, low water intake, workload, occupation, food allergy, smoking, age, chronic diseases, and stress.

Appendices
Appendix A

FIGURE 1 :
FIGURE 1: PRISMA flow diagram of the systematic review PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

TABLE 1 : Characteristics of the included studies
IBS: irritable bowel syndrome